Basic Information
| Provider Information | |||||||||
| NPI: | 1295788404 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDWARD W. SPARROW HOSPITAL ASSOCIATION | ||||||||
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| OtherOrganizationName: | SPARROW MEDICAL GROUP EASTSIDE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173648686 | ||||||||
| FaxNumber: | 5173648685 | ||||||||
| Practice Location | |||||||||
| Address1: | 2909 E GRAND RIVER AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489124300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173648686 | ||||||||
| FaxNumber: | 5173648685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | GALLUPS | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PROFESSIONAL BILLING | ||||||||
| AuthorizedOfficialTelephone: | 5173646251 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EDWARD W SPARROW HOSPITAL ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080C361700 | 01 | MI | BCBS GROUP NUMBER | OTHER |